Forgery Report Form for Controlled Substances

Cat. No.: HC/SC 4004 (10-2004)

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  • Office of Controlled Substances File No.
  • Name of the pharmacy or establishment
  • Street
  • City
  • Province
  • Postal code
  • Telephone number (   )
  • Date (YYYY-MM-DD)
  • Rx No. if filled
  • Written
  • Verbal
  • Name of product
  • Quantity & dosage form
  • Name & address of the individual named on the prescription
  • Practitioner (name & address)
  • If the prescription was not filled, briefly describe what happened and any other pertinent information
  • Attachment
    • Yes
    • No
  • For each prescription filled, name and licence number of the pharmacist who filled it.
  • Name and title of reporting pharmacist or practitioner (printed)
  • Licence or permit number
  • Date (YYYY-MM-DD)
  • Signature
  • Submit to:
    National Compliance Section
    Office of Controlled Substances
    Health Canada
    A.L. 0300B
    Ottawa ON K1A 0K9
    Tel: 613-954-1541
    Fax: 613-957-0110
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